Healthcare Provider Details

I. General information

NPI: 1154070282
Provider Name (Legal Business Name): KRISTEN VACCARO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

19 FOREST GATE CIR
OAK BROOK IL
60523-2129
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-1925
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number100231
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125.079357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: